This case study looks at the work of the Mental Health Intensive Support Team (IST), NHS England with an NHS IAPT Provider: North Tyneside. The use of an ‘interim pathway’ designed to clear waits in order to implement new and sustainable pathways is discussed. The case study is connected to a Waiting List Initiative inviting bids to clear waits within IAPT services. Following a visit by IST, funding was agreed with the provider.

Introduction

This case study looks at the work of the Mental Health Intensive Support Team (IST), NHS England with an NHS IAPT Provider: North Tyneside. The use of an ‘interim pathway’ designed to clear waits in order to implement new and sustainable pathways is discussed.

The case study is connected to a Waiting List Initiative inviting bids to clear waits within IAPT services. Following a visit by IST, funding was agreed with the provider.

The North Tyneside Talking Therapies Service had inherited large waiting lists as a result of a re-tendering process. In order to clear waits to get to a sustainable position understood by using capacity and demand modelling, the service needed to do something innovative as ‘business as usual’ would not clear waits. A waiting list initiative based on an interim six session focussed CBT Model with therapists seeing 25 patients per week to clear the High Intensity waiting list was agreed.

Waiting List Initiative

Methodology

The service combined two separate Step 3 waiting lists with patients waiting for CBT Therapy.

Waiting list validation. Mental Health Practitioners and Senior Therapists reviewed all cases based on information given at referral, assessment and identified problem descriptors.

Patients who presented with trauma and OCD were ruled out as it was felt that these two presentations would not benefit or recover within a 6 session therapy model.

Of the total 511 cases waiting; 459 were identified as appropriate for the waiting list initiative.

A “waiting list initiative” label was placed on identified patients’ electronic record held on IAPTus (patient management system).

Eight whole time equivalent therapists were recruited using recruitment agencies and a further two service employees working additional hours were also recruited to work on the interim pathway offering a 6 session therapy model to work through the combined list of identified cases.

Each wte therapist held a caseload of 25 patients seen on a weekly basis.

All service employed staff were informed when removing patients from the waiting list to select the patients who had not been identified. This enabled therapists to offer patients presenting with OCD or Trauma a course of treatment as necessary to achieve maximum recovery results.

Waiting List Initiative or interim pathway patients were also offered a 6 month subscription to ‘The Big White Wall’; this is a guided support selection of structured online programmes. Members can subscribe to a course on managing anxiety, or managing depression. Members take a Minimum Data Set before they can access each week’s session content.

The service developed a strict DNA and Cancellation policy which included a Therapy Contract specifically for use within the initiative and therapists discussed the importance of attendance at initial treatment sessions. Both clinician and patient signed the contract of understanding regarding this.

Results

Waiting List Results:

No of patients on Step 3 waiting list

Weeks

7 Jan 16

25 May 16

0-3

24

55

4-7

42

15

8-11

57

6

12-15

46

4

16-19

43

1

20-23

78

2

24-27

52

28-31

34

2

32-35

28

36-39

35

40-43

37

44-47

22

48-51

8

52-55

1

56-59

1

60-63

1

64-67

1

68-71

1

>72

Grand Total

511

85

Treatment results:

Attendance

%

Cancelled (Patient)

21.18%

Cancelled (Provider)

3.04%

Arrived late, but was seen

0.26%

Attended on time

63.24%

Did not attend

12.02%

Late (Not seen)

0.26%

Referral Status

#

Finished course of treatment

254

Not seen

1

Single treatment

107

In Treatment

97

Grand Total

459

Discharge Reason

#

%

Signposted elsewhere

21

5.8%

Declined treatment

76

21.0%

Deceased (assessed only)

2

0.6%

Completed scheduled treatment

152

42.0%

Dropped out of treatment

100

27.6%

Referral to non-IAPT service

11

3.0%

Grand Total

362

Attendance

%

Cancelled (Patient)

21.18%

Cancelled (Provider)

3.04%

Arrived late, but was seen

0.26%

Attended on time

63.24%

Did not attend

12.02%

Late (Not seen)

0.26%

Recovery Results:

Recovery (as defined by IAPT caseness to non-caseness)

34.85%

Reliable Improvement (improved by 5 points or more on PHQ9 and GAD7)

63.49%

Conclusion

The waiting list initiative was successful in reducing the waiting list in both size and length of wait.

Although recovery was below the national target of 50%, the high number of declined treatments (patients who were contacted and offered a course of therapy and stated they no longer wished to be seen) and dropped out (patients who failed to engage for their full course of therapy) had a negative impact on achieving this recovery target. However, it is important to note that the reliable improvement rate was higher than the nationally set target and national average rate of 60%. This reflects that although patients may not have met the IAPT definition of cases, they showed a high level of reliable improvement.

Keys to success

A clear understanding of the problem

The service understood the extent of the problem and had made many attempts at clearing their waits including Computerised Cognitive Behavioural Therapy.

An openness to new ideas and challenges

The service was very receptive to the idea of an ‘interim pathway’ where patients are offered ‘something rather than nothing’.

Leadership

The leadership team had a clear vision and objective but their engagement with staff meant that the waiting list initiative was ‘owned’ by everyone. Everyone was clear in regard to their responsibilities. Whilst there were challenges to the process leadership held the line and maintained a strong grip on the process.

Good and trusting relationships

The openness of everyone involved despite a difficult financial climate and pressures on all stakeholders within the health community, resulted in things being able to progress quickly and transparently.

Impact

The aim of the Waiting List Initiative was to create an interim pathway to clear waiting lists. The service was successful in this but they reported additional gains including a change to the culture of the service. Where therapists had been “very kind but not effective”, the new pathway with clear boundaries was beneficial to both patients and clinicians. Whilst initially resisted by staff, a return to a ‘pure’ IAPT model improved clinical outcomes and staff morale. The service has increased its recovery by 10 per cent and the commissioner has plans to use the methodology with the step 4 waiting lists.

Clearing backlogs and waiting lists is difficult and many services fail despite additional funding. Using an interim pathway, bespoke to individual services, is one way of addressing this problem. IST can provide support with this and demonstrate how to use the methodology. This case is an example of IST working with provider/commissioner to support a waiting list initiative to successfully reduce waits and, in this case, improve services for patients and staff.

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